Clinical guidelines

Who asked: Senior clinicians with responsibilities for medical education

What did they say?: Can you:

Write a Clinical Guidelines Policy for the Trust

Ensure the clinical guidelines process meets governance requirements

Transform paper-based system into an electronic system

Make clinical guidelines easy to access

Organise and update existing clinical guidelines

Provide a focal point for all clinical guidelines in the Trust

What did you do?: With top level support of senior clinicians, I sent an email invitation to all staff with clinical responsibilities if they were interested in being part of a Trust-wide Clinical Guidelines Group. The first meeting was chaired by a senior member medical education who shared his vision and a Chair was elected.

I wrote a Clinical Guidelines Policy with contributions from the Clinical Guidelines Group and got it agreed through the Trust process by Clinical Governance. Spread sheets were created to keep records of all clinical guidelines and expiry dates of a maximum of 3 years introduced.

Find a willing IT person to help create a clinical guidelines site on the Intranet. At the same time asking the Clinical Guidelines Group and junior doctors what they wanted from such a site. Making access easy was really important and this led us to have 3 ways of access guidelines on the site to suit different search styles:

A-Z list

Search box – keyword searching

Specialty list – some just wanted their departments guidelines

Whilst the clinical guidelines site has changed over the years, these access points have remained and with the most recent site an additional access point of “popular search terms” automatically updates itself.

Junior doctors were given printed medical guidelines at induction so the first step was to quickly get these onto the intranet site.

Departments were then asked to submit any guidelines they had to the Clinical Guidelines Group so that it could go through the official process and be added to the intranet. Staff also went through the Intranet to identify clinical guidelines that had not gone through the new process.

Templates and help sections were written and added to the Intranet along with useful links.

Later developments included adding calculator tools

How did it help?:

1. Access to good quality clinical guidelines is important to patient safety and patient care and LIKS has supported improvements in this area by on-going involvement in this process from initial development to on-going management of clinical guidelines. Clinical guidelines capture best practice and help junior staff work safely and have access to senior clinicians knowledge derived from years of experience in the form of a guideline.

2. You need senior staff with influence to drive the process forward especially at the start. A group of staff from a wide range of clinical areas is important as they bring a breadth of experience and knowledge to the review and ratification process which ensures the quality and consistency of the guidelines. These staff also add weight to the promotion and dissemination of clinical guidelines and get them used in practice.

3. A policy approved by the Organisation adds weight to the process and has ensured that people use the same format for writing guidelines and get them approved through this process.

4. There is one focal point for clinical guidelines in Northumbria Healthcare NHS Trust and statistics show it is heavily used. The intranet/internet site is key to success and making access as easy as possible is vital to this.

5. Easy access and a good site is not the whole story. Engaging with staff to get them to update/write new guidelines and disseminating guidelines is also important to ensure the quality of the guidelines and that they are used in practice.

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